The opening of a new medical school in 2020 is expected to help alleviate physician shortage issues over time. Fresno is plagued by pollution and poverty and its residents suffer from high rates of asthma and obesity. Kaiser is scrutinizing social determinants of health, but that initiative is at an early stage. As the state’s agricultural heartland, Fresno has a unique payer mix with hundreds of thousands of people reliant on Medicaid, meaning market influences have less weight than government intervention. Payment innovation is at a low level because the market centers around a great number of federally qualified health centers serving Medi-Cal patients. Health systems are focusing on drug compliance, with retail pharmacies inside their facilities and greater utilization of social programs to ensure patients get drugs and receive follow-up care to become adherent. Expect population health programs to dramatically increase as more partnerships between providers and insurers offer the data needed to make improvements.